Bleeding Per Rectum

History

Fact

Explanation

Bleeding per rectum

Fresh blood may be found in hemorrohids, [8] anal fissures etc. Passage of formed stool mixed with blood is suggestive of an anorectal bleeding. Altered black blood is associated with right sided colonic malignancies. [7] Melena is black tarry stools, may be due to upper GI bleeding. Hemochezia is the passing of red blood via the rectum usually from the lower gastrointestinal tract, and usually associated with angiodysplasia like conditions.

Frequency and duration of bleeding [7]

Bleeding per rectum which is persistent or intermittent is a common symptom in polyps. Acute onset may be due to diverticular disease, angiodysplasia, jejunoileal diverticula, meckel’s diverticulum, neoplasms/lymphomas, enteritis/Crohn’s disease. [1,2]
Peptic ulcer disease, gastritis/duodenitis and esophageal varices are the causes of upper gastrointestinal causes for the acute rectal bleeding. Angiodysplasia, small bowel tumors, small bowel ulcers and erosions, crohn’s disease, small bowel diverticulosis, and radiation enteritis are causes for chronic intermittent bleeding. [7]

Pain

Painless bleeding may be due to hemorrohids, [8] colorectal carcinoma, polps, diverticular disease and Bleeding will be painful in anal fissure which is a severe sharp pain occurring with straining on defecation and resolves within an hour after defecation. Strangulated hemorrhoids are usually associated with pain. [8]

Age [7]

Diverticular disease, arteriovenous malformations, colorectal carcinoma [7] and polyps are known to be more common in elderly people. Meckel's diverticulitis, intussuseption is more common in infants and young children. Inflammatory bowel disease is common in the age between 20-40 years. Anal fissures and hemorrhoids are also common in young age group. [8]

Tenesmus [11] and sense incomplete evacuation of the rectum [7]

Tenesmus is painful desira to defecate without passage of stools. Constipation may be chronic. [4] These symptoms are usually occurred in lower GI neoplasms.

Constipation [4] and diarrhoea

Alternating constipation and diarrhoea is a feature of lower GI malignancies. Anal fissures [11] are more common in patients with history of constipation. Inflammatory bowel disease may also cause diarrhoea. [11]

Lump at anus

Is due to the haemorrhoids. [8] Occasionally a polyp or rectal prolapse may be the cause.

Haematomesis

Passage of blood with vomitus may be indicative of upper GI bleeding. Peptic ulcer disease [12] may occasionally presents with lower GI bleeding.

Abdomonal pain[4]

Right sided colonic malignancies can cause right sided abdominal pain. Intestinal obstructuin by an annular growth also may be possible. [4,7]

History of radiation to abdomen and/or pelvis

Radiation colitis may be due to radiation treatment. [13]

Extraintestinal features:uveitis, joint pain

Associated features in autoimmune conditions like Inflammatory bowel disease.[11]

Shortness of breath on exertion, lethargy [6]

Intermittent chronic blood loss may cause amaemia. [1] Low oxygen to the tissues due to the anaemia, causes lack of energy.

Diet [9]

Increased fat in diet, high intake of red and processed meats,[10] highly refined grains and starches, and reduced fibre are known to increase the risk of colorectal carcinoma. Fiber [9] dilutes or adsorbs fecal carcinogens, modulates colonic transit time, alter bile acid metabolism, reduce colonic pH, or increase the production of short-chain fatty acids, by which it reduces the risk of colorectal cancers. [3]

Differential Diagnoses

Fact

Explanation

Colonic polyps [11]

Polyps are colonic mucosa overgrowths that carry < 1% risk of becoming malignant. Bleeding per rectum [11] which is persistent or intermittent is a common symptom in polyps. Inflammatory, juvenile, peutz-Jeghers, are the various types of polyps. Colonoscopy allow both diagnosis and the immediate therapeutic polypectomy. [4] Adenomatous and Peutz-Jeghers polyps need follow up with fibre optic colonoscopy for the recurrence and malignant changes. [5]

Haemorrhoids [13]

This usually presents with painless rectal bleeding [13] with passage of mucous which is usually noticed during defecation. Person may notice a lump at anus which is manually or spontaneously reducible at the early stages and not reducible at later stages( stage 3) In advanced cases such as complicated with fibrosis, gangrene formation, necrosis and infections, it may cause pain. [13]

Colonic malignancies [7]

Right-sided colonic bleeding [7] present with bright red blood in the case of massive bleeding is brisk. Otherwise it presents with dark altered blood or malena. Left-sided bleeding may be bright red. Intestinal obstruction can occur in colonic malignancies. Presentation would be abdominal pain, constipation, vomiting and abdominal distension. Loss of appetite and loss of weight and other features of dissemination of the malignancy may be present. [7] Right sided bleeding may be present with iron-deficiency anemia. [8]

Rectal malignancy

Painless rectal bleeding may be associated with altered bowel habits [7] such as alternating constipation and diarrhoea, tenesmus [9] (pain during defecation) and sense of incomplete evacuation of the rectum. Loss of appetite and loss of weight [7] and other features of dissemination of the malignancy may be present.

Angiodysplasia [10]

Angiodysplasia commonly affects the caecum and ascending colon less commonly located in the jejunum and/or ileum and the remainder are throughout the alimentary tract. [1] It is a significant cause of bleeding in the elderly people. [1] Degenerative pathology with aging is known to be associated. Lesions occur due to the intermittent partial chronic obstruction of the submucosal veins at the points where they penetrate the muscle layers of the colon. [2] Usually it will be altered blood with a maroon-colored stool.

Diverticular disease [3]

Acute painless bleeding, with mild abdominal cramping due to the intraluminal blood and increased pressure [11] may be the presenting symptoms. Majority will have pain in the left lower quadrant, Fever may also present. May be recurrent. Sometimes bleeding may be massive causing hypotension and shock. Pneumaturia is a significant finding in colovesical fistula. [1] Perforated disease may have features of generalized peritonitis like tenderness, rebound tenderness, rigidity in the abdomen. Water-soluble contrast enema, CT scan, and ultrasound are the investigations done during the acute phase of diverticular disease. [11]

Investigations - for Diagnosis

This is the first line investigation in lower GI bleeding. [3] It usually examine upto splenic flexure of the colon. Intestinal growths, ulcers, polyps etc may be found on sigmoidoscopy. [3]

Colonoscopy

This is an important diagnostic tools to evaluate acute lower gastrointestinal bleeding. Colonoscopy is more sensitive and accurate than sigmoidoscopy in diagnosis. These may be operator dependent. Active bleeding will limit the use of the investigation. It is also important as to exclude the other lesions in the colon before the hemicolectomy. [2]

Stool occult blood test

Stool for occult blood is positive even in asymptomatic people. [2]

Angiography

Clusters of small arteries during the arterial phase at the antimesenteric border, accumulation of vascular spaces and opacification of the bowel during the capillary phase, early opacification of the veins draining the caecum and ascending colon are the features for the diagnosis of angiodysplasia on angiography. [1]

Technetium-labeled red blood cell scintigraphy

Is able to detect active gastrointestinal bleeding even at a low rate. [1]

Investigations - Followup

Syndromes like heredetery non polyposis colorectal carcinoma (HNPCC) has a high risk of malignant transformation [5] and need regular follow up. It is recommended to screen every 2 yearly from the age of 25, and5 years younger than the earliest affected case in the family up to 75 years. [2]

Investigations - Screening/Staging

Some patients have the underlying cardiac disorders that can cause low perfusion and ischaemia of the walls of intestines. [1]

CT scan, MRI scan

To stage the disease in colorectal carcinoma. [2]

Carcinoembryonic antigen (CEA) [4]

Plasma level of carcinoembryonic antigen (CEA) is measured preoperatively in a suspected case of colorectal malignancy. [3] It may also be elevated in other conditions like gastric carcinoma, pancreatic carcinoma, lung carcinoma, breast carcinoma, and medullary thyroid carcinoma, as well as some non-neoplastic conditions like ulcerative colitis, pancreatitis, cirrhosis, COPD, Crohn's disease. [3]

Management - General Measures

Fact

Explanation

Resuscitation

Patients can present with acute massive gastrointestinal haemorrhage needing resuscitation. [5] Special attention should be focused on circulation due to the massive blood loss. Volume resuscitation may be needed.

Management of anaemia [6]

Anaemia can be due to chronic intermittent blood loss from gastrointestinal tract, malignancy induced inflammation and underlying comorbidities. [6] If significant anaemia present with clinical features they need to get treatment and if needed even blood transfusion.[6]

Pre op angiography

Selective angiography is recommended for the preoperative localization of bleeding sites. [1]

Reducing the risk of colorectal carcinoma

Clinical trials have shown that aspirin in doses as low as 325 mg per day reduces risk of colorectal carcinoma. [3] Reduction of fat in diet is also an important measure. Avoidance of smoking and heavy alcohol use, prevention of weight gain, and the maintenance of a reasonable level of physical activity are known to lower the risks of colorectal cancer. [4]

Management - Specific Treatments

Fact

Explanation

Management of colorectal carcinoma

Surgery is the most important part in the treatment of rectal cancer. [4] Stage T1 and T2 local excision is possible. Local excision combine with pre- or postoperative radio-chemotherapy gives the good the outcome. Transanal endoscopic microsurgery (TEM), is a new technique that provides a locally curative operation. [6] High ligation of the interior mesenteric artery, will be beneficial. Minimum margin of mesorectum should be 5 cm. There are main 2 types of surgical options available: Abdominoperineal resection (APR) and anterior resection. [1] Anterior resection is a sphincter-sparing operation that gaining the popularity. Abdominoperineal resection (APR) does not preserve the sphincters.
Intravenous Fluorouracil, oral fluoropyrimidines, angiogenesis Inhibitors, epidermal Growth Factor Receptor Inhibitors in isolation[3] or as combined treatment is used as systemic therapy for the colorectal cancers. [3]

Management of polyps [10]

HNPCC is an autosomal dominant condition with a mutation in DNA mismatch repair genes. [2] This condition has a high chance of developing colorectal carcinomas. Prophylactic colectomy will be needed in high risk people. [10] Single staged subtotal colectomy with ileosigmoidostomy is the treatment for multiple polyps. [10]

Management of haemorrohids [5]

Constipation or other causative factors needs to be corrected. [5] Sitz baths are used to reduce swelling and sphincter spasm. [5] Injection sclerotherapy, band ligation and surgical treatment are the other options available.

Management of angiodysplasia

Conservative approach is suitable for the hemodynamically stable patients as bleeding can stop spontaneously in the majority of patients.[1] Surgery is the management option with highest cure rate. It is done when the endoscopic ablation is not suitable or if life-threatening hemorrhage occurs. Right hemicolectomy or if relevant total colectomy is done.